The Case for the Patient-Centered Medical Home in Correctional Health Care Julie White, MSW Senior Director of Operations Health & Criminal Justice Program University of Massachusetts Medical School
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The Case for the Patient-Centered Medical Home in Correctional Health CareJulie White, MSWSenior Director of OperationsHealth & Criminal Justice ProgramUniversity of Massachusetts Medical School
“I do not have any relevant financial relationships with any commercial
interests”
Faculty Disclosure
22
• Examine the complexities of providing comprehensive health care to individuals who are incarcerated
• Describe the patient-centered medical home (PCMH) model
• Examine how an Implementation Science framework can serve as a basis for planning, implementation and sustainability
Educational Objectives
33
The concurrent prevention and management of multiple physical and emotional health problems of a patient over a period of time in relationship to family, life events and environment. (CGA) (1980) (2013 COD)1
What is Comprehensive Health Care?
4
1. http://www.aafp.org/about/policies/all/care-definition.html
4
What are the unique challenges related to providing comprehensive health care in correctional facilities?• Mission• Silos• Limited resources and space• Complex comorbidities• Care coordination• Reentry planning• Costs
Challenges of Providing Comprehensive Correctional Health Care
5
• Correctional Facilities– Safety, security, care, control, containment,
supervision• Health Care Organizations
– Improve health care outcomes, patient-centered, inclusive, fostering healthier lifestyles, caring, convenient, cost-effective and accessible manner
Missions
6
Silos
7
• Pharmacy• Imaging• Dentistry• Dieticians• Mental health
– Social workers, psychologists, psychiatrists, mental health counselors
• Medical – MDs, advanced practitioners, nursing, allied health
Health Care Silos
8
• Security staff• Executive team• Administrative staff• Substance abuse treatment staff• Reentry staff • Education staff• Institutional caseworkers• Food Services
Correctional System Silos
9
What About the Patient?
10
Incarcerated populations have higher rates of mental illness, chronic medical conditions and infectious diseases compared with the general population.2,3,4
Complex Comorbidities
11
2. James DJ, Glaze LE. Bureau of Justice Statistics special report: Mental health problems of prison and jail inmates. 2006. Available from: http://bjs.ojp.usdoj.gov/ content/pub/pdf/mhppji.pdf.3. Maruschak LM. Bureau of Justice Statistics bulletin: HIV in prisons, 2005. 2007. Available from: http://www.bjs.gov/ content/pub/pdf/hivp05.pdf.4. Weinbaum CM, Sabin KM, Santibanez SS. Hepatitis B, hepatitis C, and HIV in correctional populations: A review of epidemiology and prevention. AIDS 19(Suppl 3):S41–6. 2005. 7. Carson EA, Sabol WJ. Bureau
• Research demonstrates that in jail populations, of the approximately 17% with serious mental illness, an estimated 72% had a co-occurring substance use disorder5
• Another study found that approximately 59% of state prisoners with mental illness had a co-occurring substance use disorder6
Complex Comorbidities
12
5. Abram, Karen M., and Linda A. Teplin, “Co-occurring Disorders Among Mentally Ill Jail Detainees,” American Psychologist 46, no. 10 (1991): 1036–1045.6. Ditton, Mental Health and Treatment
• Coordination– Social services, substance abuse, medical
care, mental health• Stable housing
– The elephant in the room• Paying for healthcare
– ACA, activating Medicaid vs no access to Medicaid
Reentry
13
• In a 2007 publication, Binswanger, et al found that Washington State inmates had a statistically higher mortality rate in the first two weeks post release compared to Washington State non-incarcerated residents of the same age, race and sex7
• The leading cause of death in two weeks post release was drug overdose– Released inmates were 129 times more likely to die from a drug
overdose than those in the community
Reentry and Mortality
14
8 http://www.nejm.org/doi/full/10.1056/NEJMsa064115#t=article
The study also identified other elevated risk factors released inmates must face including, cardiovascular disease, homicide and suicide.
Reentry and Mortality
15
Emerging research suggests that underlying health issues, particularly substance use disorders and mental illness, contribute to incarceration and recidivism, and that treatment, combined with seamless care continuity for individuals when they return to communities, can help prevent both.8
Reentry
168. http://www.pewtrusts.org/~/media/assets/2017/10/sfh_prison_health_care_costs_and_quality_final.pdf?la=en 13
• 2017 report from Pew Charitable Trusts, Prison Health Care: Costs and Quality looked at “how and why states strive for high performing systems.”
• In 2015, total state prison health care spending was $8.1 billion
• From scale 2010 to 2015, real per-inmate spending rose by a median of 2 percent.9
Costs
179. http://www.pewtrusts.org/~/media/assets/2017/10/sfh_prison_health_care_costs_and_quality_final.pdf?la=en
• Institute for Healthcare Improvement• Integrated health care• Patient-centered medical home
(PCMH)
What is happening in the community?
18
The Institute has articulated three broad critical healthcare reform objectives, known as the Triple Aim:
• Improve the health of the population;• Enhance the patient experience of care (including
quality, access, and reliability);• Reduce, or at least control, the per capita cost of total
healthcare 10
Institute for Healthcare Improvement’s Triple Aim
1919
10. http://www.ibhpartners.org/wp-content/uploads/2015/12/Business_Case_for_Integration_6-10-Mauer.pdf
• In response to the Affordable Care Act and payment reform efforts, community-based systems are embarking on new models of integrated care in preparation for capitated care systems with aligned financial incentives and risks
• To this end, integrated primary care/behavioral health PCMH models have been implemented across various practice settings
• Large initiatives have been funded through the Centers for Medicare and Medicaid Services Innovation Center’s Transforming Clinical Practice Initiative
Integrated Health Care
20
• Healthcare reform, beyond insurance coverage expansion, is focused on investing more of the healthcare dollar in better primary care systems (known as Patient-Centered Medical Homes) to achieve the Triple Aim
Patient Centered Medical Home Model (PCMH)
2122
A PCMH is a care model that involves the coordinated care of individual’s overall health care needs and where patients are active in their care11
Integrated PCMH
22
• A health home offers coordinated care to individuals with multiple chronic health conditions, including mental health and substance use disorders.
• It is a team based clinical approach that includes the consumer, his or her providers, and family members when appropriate.
Integrated PCMH
23
The health home: • Builds linkages to community supports and
resources • Enhances coordination and integration of
primary and behavioral health care to better meet the needs of people with multiple chronic illnesses
Integrated PCMH
24
There is ahift in focus from episodic acute care to care for the whole person• Team-based care focused on the whole person
and achieved through coordinated care
Integrated PCMH
25
• Comprehensive Care Team Physicians, advanced practitioners, nurses, pharmacists, social workers, educators, care coordinators
• Patient Centered CareAddresses unique needs each patient, their cultures and values
• Coordinated CareEHR, physical space
• Accessible ServicesHours, wait times
• Quality and SafetyEvidence-based and incorporating clinical decision support tools
Core Elements of Integrated PCMH
26
Such teams have developed in various treatment settings, including community health centers, hospitals, behavioral health clinics, VA medical centers, and Health Care for the Homeless clinics
PCMHs in other settings
27
What outcomes are you interested in?
• Quality Improvements • Health Outcomes• Provider Satisfaction• Cost Benefit Analysis
Where’s the data?
2831
• Data indicated that the Mississippi Integrated Health and Disaster Program’s integrated health model significantly improved depression, anxiety, and diabetic self-care among chronic care patients.12
Mississippi Integrated Health and Disaster Program
2932
• This business case paper is intended for audiences who want accomplish healthcare objectives of the Institute for Healthcare Improvement’s Triple Aim.
• Summarizes case studies & outcome data; argues the need for integrated care to improve healthcare quality and manage expenditures.13
The Business Case for Bidirectional Integrated Care
3033http://www.ibhpartners.org/wp-content/uploads/2015/12/Business_Case_for_Integration_6-10-Mauer.pdf
• There is a lack of research regarding the development and implementation of integrated PCMH models in correctional settings
• Obvious barriers to implementation exist despite the fact that many correctional health care systems have been funded through capitated models for many years. In fact, “multiple correctional and medical roles can undermine patient-centered care”14 and strict adherence to treatment protocols may undermine efforts to develop individualized treatment plans.
PCMH in Correctional Facilities
3114. https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-016-0035-9
Despite the barriers, “A Call for New Models of Care in Correctional Health,” published in the National Commission of Correctional Health Care magazine Correct Care, highlights the need to explore such a model and provides suggestions for implementation of several components of integrated care PCMH models.15
PCMH in Correctional Facilities
3215. http://www.ncchc.org/filebin/CorrectCare/30-2.pdf
Given the multi-faced challenges of treating patients with complex co-morbidities in correctional facilities, the increasing adaptation of Medication-Assisted Treatment for substance use disorders in such settings, the current redundancy, inefficiencies and cost of work across different treatment disciplines, and the need for more integrated reintegration plans, models for practice transformation and integrated care must be explored in correctional settings
The Case for PCMH in Correctional Health Care
33
• Well-run, forward-thinking prison health care systems are vital to state aims of providing care to incarcerated individuals, protecting communities, strengthening public health, and spending money wisely.
• Likewise, poorly performing systems threaten to make states less safe, less healthy, and less fiscally prudent.
• Put simply: The stakes extend far beyond the confines of prison gates. 16
The Case for PCMH in Correctional Health Care
34
16. http://www.pewtrusts.org/~/media/assets/2017/10/sfh_prison_health_care_costs_and_quality_final.pdf?la=en12
37
• California Correctional Health Care Services (CCHCS) shall manage and deliver medically necessary health care services to the patient population. The Complete Care Model (CCM) is based on the industry standard known as the Patient-Centered Health Home.
• The CCM shall serve as the foundation for CCHCS health care services delivery. This model improves patient outcomes, reduces the need for hospitalizations and emergency services and enhances staff satisfaction
California as a Leader
35
How would we even begin this process?
36
The use of strategies to introduce or change evidence-based health interventions within specific settings17
Implementation Science
3717. National Institutes of Health, 2013
The scientific study of methods to promote the systematic uptake of proven clinical treatments, practices, organizational and management interventions into routine practice, and hence to improve health18
Implementation Research
3818. Aarons, G. (2013) IST Track 9th Academic & Health Policy Conference on Correctional Health
A Multiple Phase Process of Implementation• Aarons, et al. have proposed a conceptual
model that serves as a blueprint for long term planning and implementation19
• Sustainability is factored in during the initial phases and throughout the process
Exploration, Preparation, Implementation, Sustainment (EPIS)
39
19. Aarons, G.A., Hurlburt, M. & Horwitz, S.M. (2011). Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors. Administration and Policy in Mental Health and Mental Health Services Research.38, 4-23.
Inner Context:• Intra-Organizational Characteristics: Leadership,
policies, cultures, organizational structure, climate, technology capabilities, data analyses
• Individuals Adopter Characteristics: Attitudes, fidelity, individual commitment, organizational commitment, turnover
EPIS Model
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Outer Context:• Service environment • Inter-organizational environment• Patients and consumers
EPIS Model
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• Funding/resources• Contract reviews/RFR development• Leadership capabilities• Training needed• Physical space• Staff and patient surveys
Exploration
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• SAMSHA/ HRSA Center for Integrated Health Solutions have created a center promoting the integration of primary care and behavioral health. This has a wealth of resources for getting started.
• https://www.integration.samhsa.gov/integrated-care-models/CIHS_quickStart_decisiontree_with_links_as.pdf
Exploration tool
4348
• Implementation team• Coach• Trainers• Administrative buy-in• Clinician and staff availability
Preparation
44
The Patient Centered Medical Home Resource Center, housed at the Agency for Health Care Research and Quality (AHRQ), has a clearinghouse of established training modules.
Preparation tools
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• Space• Technology• EHR• Team huddles• Reentry planning• Work assignments
Implementation
46
• Patient satisfaction• Patient outcomes• Provider satisfaction• Provider retention• Tracking costs• Where’s the money?
Sustainment
47
• http://www.cphcs.ca.gov/docs/imspp/IMSPP-v04-ch01.pdf
• Integrating Behavioral Health and Primary Care.: Robert E. Feinstein, Joseph V. Connelly, and Marilyn S. Feinstein (2017) Oxford: Oxford University Press.
• Overview of EPIS Framework http://www.cebc4cw.org/implementingprograms/tools/epis/
• EPIS Phase Specific Supports http://www.cebc4cw.org/implementing-programs/tools/technical-assistance-materials/
Additional resources available
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